Provider Demographics
NPI:1245258490
Name:MCCLANE, STACIE D (DR)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:D
Last Name:MCCLANE
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 N. LAKE SHORE DRIVE
Mailing Address - Street 2:SUITE 1425
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:312-867-9500
Mailing Address - Fax:312-674-7501
Practice Address - Street 1:680 N. LAKE SHORE DRIVE
Practice Address - Street 2:SUITE 1425
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-867-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-106591207YS0123X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204190Medicare ID - Type Unspecified